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Getting health care to vulnerable communities

More research is needed into why vulnerable communities fail to access public health-care services even when these are
available. This lack of access proved to be tragic for Mumbai slum-dweller Savita Das and her family.

Rupa Chinai

Savita Das and her five children.

On 26 July 2005, when Mumbai was flooded within hours, Savita Das, 35, faced a decision no woman should have to make. Savita’s 10-month-old daughter had fallen into the dirty floodwaters and urgently needed to be taken to hospital. The child was already suffering from severe malnutrition and the floods made her diarrhoea and respiratory infection even worse.

But as a widow living with her six children
in a slum on the edge of the city, Savita
had no choice but to watch her youngest
child die. She recalled with sadness how she named that child “Lucky” in defiance of the family’s already bad fate.

“I knew my baby had to be taken
to a hospital. But I have five other
small children. Who would look after
them if I am away for more than a
day?” Savita said, referring to her
daughters: Sujata, 9, Supriya, 6, and
Kantari, 5; and sons: Amar, 4, and
Chaman, 2, who were also malnourished
and unwell before the floods.

“If I take time off from work, how
will I feed them?” said Savita, who
earns around 50 rupees (about US$ 1)
a day, after eight hours of back-breaking
work at a scrap warehouse, separating
plastic and other products that are
used by the recycling industry.

Savita’s story illustrates one disconnect,
among many, that sometimes
exists between public health
policy and practice. While the Indian
government’s health policy is aimed at
helping women like Savita, in practice
such people often fail to access available
health-care services for a number
of reasons.

Addressing this disconnect is vital
for making public health services more equitable in developing countries. This
was a core issue at the annual meeting
of the Global Forum for Health
Research in Mumbai, 12–16 September,
attended by 700 international
researchers and public health experts
whose theme was “poverty,
equity and health
research”.

The Geneva-based nongovernmental
organization (NGO) campaigns for more
research and development funding for the
diseases of the poor and more funding
for research into how to improve service
delivery to vulnerable communities like Savita’s.

Just weeks before the flood hit
Mumbai, a local NGO, the Society
for Nutrition, Education and Health
Action (SNEHA), demonstrated how,
in practice, such research can indeed
come to the aid of vulnerable and
impoverished communities. They and
others involved in similar work believe
that research into health systems and
how they function on the ground can
save lives in such communities.

In a study of six wards in Mumbai,
the NGO identified Bhim Nagar
as one of the most vulnerable communities
because of its lack of access to
basic shelter, hygiene and health care.

In the absence of these basic
services, the group knew that — even
though the slum was not one of
the worst flood-affected areas — its
people were likely to suffer more than
those living in better-served parts of
the city.

Rupa Chinai

Savita’s five children outside their makeshift home in Bhim Nagar.

A team of doctors and social
workers from SNEHA reached Bhim
Nagar on the third day after the deluge.
They brought food, medical aid
and counselling, but it was too late to
save Lucky, who died on 4 August.

The group’s research findings
ring true for Savita. When Savita’s
mother died because the family could
not afford medicines to treat her high
blood pressure, Savita’s children lost
their support system while she and her
husband were out working.

Seven months later, Savita’s husband
Kewal, a construction worker,
died of gastric-related problems. His
daily pay of 60 rupees barely provided
the family with a frugal diet of rice
and lentils and certainly not enough
to buy the drugs prescribed for him by
government hospital doctors.

“Savita’s inability to access timely
health services for her child is a consequence
of her circumstances,” said Dr
Armida Fernandez from SNEHA, calling
for the provision of mobile health
services to such communities.

Savita’s family are Bengali speakers
who came to Mumbai from Assam. They are among some seven million urban poor who constitute 60% of Mumbai’s population of 12 million. They live on the streets, in slums, tenements and dilapidated buildings.

Communities living in slums
established before 2000 are provided
with basic health-care services, but
unregulated ones like Bhim Nagar that
have sprung up since then are subject
to evictions and are not provided with
basic services, such as clean water,
health services, schools, electricity and
ration shops.

Bhim Nagar is built on a vast marshy
swamp, and patients requiring medical care
must be carried for 30 minutes along a dirt
track before they reach the road and transportation.

“Reaching a government hospital
does not save their lives. They are asked to
purchase expensive drugs from outside,
made to run from pillar to post and wait
in long queues,” said Sangita Kamble, a
social worker who works in Bhim Nagar.
“Those who have money prefer going to
private doctors or quacks. The rest, like
Savita, give up hope.”

Mumbai has one of the wealthiest
municipal authorities in India. Its
health-care services are, however,
stretched beyond capacity because of a
rapidly growing population and a state
government freeze on recruitment of
new health staff over the last six years,
said Jairam Thanekar, Deputy Executive
Officer of the Mumbai Municipal
Corporation.

This situation is severely affecting
primary and secondary care services
where limited staff shoulder the burden
of having to implement all “vertical”
or single-disease programmes, said Dr
Girish Ambe, Deputy Executive Health
Officer for Tuberculosis. The main
vertical programmes are on family planning,
polio, AIDS, tuberculosis, malaria
and immunization.

Thanekar said the city would
benefit from research into a number of
disconnects in the health system. For
example, research on how to develop
human resources because low motivation
and morale among health staff are major obstacles faced by patients seeking
public health-care services.

Ravi Narayan of the People’s
Health Movement, an international
NGO, said an important message that
emerged from the Global Forum’s
meeting, Forum 9, was that communities
need to become more involved in
shaping research agendas. Evidence
from Africa and Asia shows how
research that brings together statistical
data with information on what
communities want, based on interaction
and sharing knowledge with them, can spur more active involvement of communities.
This would make health policy and service delivery more effective, he said.

Lot Nyirenda, a scientist with Research
for Equity and Community Health Trust in
Malawi, agreed that it is vital for local research to help determine what are the priority concerns of a developing country: “Policies for research and equity need to be developed in a manner that is participatory and relevant to local needs. It should aim at reaching the most marginalized segments of the population by ensuring mechanisms that provide proof of delivery”.

Bhim Nagar is one of many communities
across Asia that would benefit if user fees for health-care services were eliminated and if budgets were increased to strengthen the public health system. Savita’s poignant story of failing to access life-saving health
care is repeated in many places across the world.

A study called Equity in Asia-Pacific Health System (EQUITAP) looking at 15 Asian countries — including India — that was presented at Forum 9 found that charging user fees and withdrawing public sector
money to fund health care for the poor were resulting in catastrophic out-of-pocket expenditure for the poor, plunging them into indebtedness and deeper poverty.

WHO estimates that worldwide
180 million people suffer financial
catastrophe every year because of user
fees for health care and because of
these fees, some 105 million people are
impoverished.

Stephen Matlin, Executive Director of the Global Forum for Health Research, said that many countries fail to provide universal access and free services, and the limited resources that are spent on health are not well targeted. “A relatively large proportion of the public resources benefit the better-off
rather than the poor in society,” Matlin told the Bulletin.

“The research challenge lies in how to redirect public resources to the poor,” Matlin said.